Client Weekly Update Client Name* First Last Primary Counselor*Select your counselor hereRashad HameedVictoria LindleyMikare MichiraKaonou VueRachael CavegnOtherCONTACT DETAILSEnter Your Current Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Enter Your Current Phone #:*Enter your Current eMail:* What is your preferred contact method? Phone Call Text Message eMail Doesn't Matter TREATMENT DETAILSCurrent Phase* One Two Three Four Legacy Attendance Days* Monday Tuesday Wednesday Thursday Friday Are you in a recovery residence?* Yes No Which one?* Move-in Date:* MM slash DD slash YYYY Stipend Level:* Full Stipend 3/4 Stipend 1/2 Stipend 1/4 Stipend N/A - No Stipend SUBSTANCE USE & WITHDRAWAL ASSESSMENTWhat is your last date of substance use?* MM slash DD slash YYYY What did you use on that date?* Have you consumed any of the following substances since your last update?*Check all that apply Alcohol Marijuana Benzodiazepines Heroin Opiates/Opioids Methamphetamine Ritalin/Adderall/Etc Cocaine Molly/MDMA Inhalants Salvia LSD/Hallucinogens Synthetic Cannabis Bath Salts/Cathinones Kratom Steroids DXM/Cold Meds GHB Methadone Suboxone/Subutex Pseudoephedrine Caffeine Nicotine Other OTC Meds Other Substance None of the above Are you currently receiving medication assisted treatment?* Not on MAT On Methadone On Suboxone Other MAT What is your current dose?* How long have you been at this dose?* Please describe any withdrawal symptoms you may be experiencing: PHYSICAL HEALTH & WELLNESSPlease rate how physically “well” you have felt this week:* Great Good Just Ok Not Good Awful Explain:* Any new medical/health issues?* Yes No Describe: Sleep Quality?* Great Good Just OK Not the Best Awful How many hours per night?* Have you been eating regular, quality meals?* Yes No What's getting in the way? Any medical/dental appointments this week?* Yes No What/When? Please list any new physical health meds or medication changes:* If applicable, do you take your medications as directed?* Yes No Not Applicable Do you get regular physical exercise?* Yes No Describe:* EMOTIONAL, BEHAVIORAL & MENTAL HEALTHWhat was your biggest accomplishment this week?* Have you had any thoughts of self-harm this week?* No Yes Have you acted on any thoughts?* No Yes Please talk to a staff member as soon as possible!Rate your overall mood this week:* Great! Good! Just Ok Pretty Bad Awful Rate your overall stress level this week:* Very Little A Little Medium Too Much! Extreme! Biggest stressors this week:* Name two coping skills you’ve used this week:* Do you take your psychiatric meds as prescribed?* Yes No Not Applicable Any mental health appointments this week?* Yes No What/When?* What were some significant events for you this week?* RECOVERY MOTIVATION AND PARTICIPATIONWhat is your primary motivation for being in recovery/treatment?* My Own Goals/Health Probation/Courts Child Protection Housing Family/Partner Something Else How excited have you been for recovery this week?* Very! Excited! So-So Ugh! Noooo! Please tell us how excited you've been to do the following activities this week:Treatment Group:*Attending and Sharing in Group Very! Excited! So-So Ugh! Noooo! Other Treatment Appointments:*Individual Counseling, Therapy, Peer Support Very! Excited! So-So Ugh! Noooo! Other Recovery Activities:*Recovery Meetings, House Meetings, Probation Very! Excited! So-So Ugh! Noooo! What group did you enjoy most this week?* Least?* How did you participate in the group process?* What is your biggest recovery goal right now?* RELAPSE PREVENTION/RECOVERY MANAGEMENTHow confident have you felt in your recovery?* Extremely Confident Very Confident Somewhat Confident Not Very Confident Not at All Confident Please identify any triggers that you’ve experienced this week:*Check all that apply Using Friends Family Members Partners/Spouses Bars/Clubs Old Neighborhoods Seeing Drugs/Alcohol Social Situations Celebrations Dining Out Movies/TV Sexual Encounters Money Holidays Ads/Marketing Stress Sadness Depression Frustration/Anger Irritability Dishonesty Loneliness Overconfidence Guilt/Shame Self-Loathing Discrimination/Prejudice Legal Issues Negative Thoughts Fear of Failure Wanting to Feel High Wanting to Feel Better Criminal Thrill-Seeking Longing for the Old Lifestyle Wanting to Belong Other: Have you been having trouble with any of the following behavioral challenges?*Check all that apply Overeating Restricting Food Binging/Purging Sexual Behavior Spending/Shopping Gambling Video Games Repetitive Behaviors Compulsions/Obsessions Cutting/Self-Harm Compulsive Cleaning Excessive Exercising Hair Pulling/Skin-Picking Other Compulsive Behaviors None of the Above Please list two coping skills you’ve used to help stay on track:* What/whom was most influential in your recovery this week?* RECOVERY ENVIRONMENT, RELATIONSHIPS & SUPPORT NETWORKAre you in a romantic relationship?* No Yes If so, How long? How many supportive relationships do you currently have?* 15+ 10+ 5+ A handful None Who do you consider your primary support at present?* How often do you call/text/chat with your support network?* Daily 2+ x/Weel Weekly When Needed Not Often How often do you spend face-to-face time with your support network?* Daily 2+ x/Week Weekly When Needed Not Often How often do you attend mutual/recovery support groups?* Daily 2+ x/Week Weekly When Needed Not Often Do you have a sponsor/recovery coach?* Yes No Working on it How often do you talk to them? Rate how “connected” you feel to others around you:* Very Quite Just Ok Not Very Not at all What are you doing for fun/recreation?* How are things with your sober house leader/peers?* Great Good Ok Not the Best Awful N/A Do you have any probation/court/CPS meetings coming up?* No Yes Details:* Are you following all of your legal requirements?* No Yes N/A Any new charges/arrests?* No Yes If it applies, how is work/school going for you?* Great Good Ok Not the Best Awful N/A Please rate your relationship with your counselor:* The Best Pretty Good Just Ok Not the Greatest Terrible What can they do to improve the relationship?* What can you do?* What do you like most about this program?* Least?* What would make the program better?* Anything else you’d like us to know? Δ
